Top Down | Bottom Up | Middle Out


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In his September article for PSX: People Strategy Exchange eMagazine, Marvin Smith of Deliberate Synergy explains why it takes more than just agreement to make large scale change happen.  Marvin Smith shares insights about top down, bottom up and middle out leadership, and how they are all necessary to ensure the success of large scale change projects.

marvin #3Recently I facilitated a retreat of 90 Physicians and Administrative Leaders. My experience there is the centerpiece for this short story. The task at the retreat was to create an alliance and make this a large-scale change happen. Large-scale change typically creates Discomfort, Dissatisfaction and Discontinuity. These elements can be a formula for frustration and anxiety. They cause participants to act like hostages rather than open-minded and hands-on contributors.

My role as outside facilitator was to manage this group. That was no small task as the participants all had distinctly different “DNA’s”: some entrepreneurial, some researchers, all hard working, and all with plenty else to do on that chosen Saturday. The weather was beautiful, and it was clearly a sacrifice to be inside for this activity.

The change planning team had spent a solid month doing data collection, conducting analysis, and establishing rapport with key participants, some of whom were “outliers”. We had to assure these outliyers that their voices would be heard, and they would have a key and early role in setting the stage for change. They assured us that they would not hesitate to voice their concerns, and we should “get ready”. The planning team knew the only way to insure success was to prepare, focus on the right things and relax, relate, and react.

The planning team also prepared top leadership to articulate the vision and the principles that would be necessary to make the sought after alliance a success. We wanted each leader to connect with the audience when his or her time came to speak. We prepared leadership to converse with and show empathy toward this group, rather than “present”. So, no slides were used.

We invited outsiders experienced in developing alliances to come and speak with our group. We allowed participants to ask tough questions, which these outsiders answered directly. This resulted in many rich exchanges. All of the speakers showed passion and openness to different points of view. They revealed what worked for them while sharing that in this exact form “it may not work for you”. This offered opportunities for participants to engage in “connection making” (i.e., making sense out of something that happens outside of your normal value system).

The biggest challenge the group faced was how to achieve parity and partnership in different geographical areas. Strangely enough, this challenging issue, coupled with the willingness by all participants to show empathy and openness allowed all participants to realize that no one entity could solve this issue alone.marvin #2

This situation gives raise to something I learned from a colleague of mine, Robert Boyer, who described it as Top Down, Bottom Up & Middle Out.

TOP DOWN leadership in a vacuum is not enough to address today’s business complexities, especially with the turmoil in healthcare where this alliance was being formed.

From my perspective, Top Down means that the view from the top is unique; leaders can stand at the periphery of the organization and look in at the strategy, culture, and results. Leaders must look at the trends, competition and government relations that create distinct boundaries. The hard-earned experiences and credentials to get to the top is still not enough. One entity dictating to (rather than involving) the other is taking a big chance that implementation will come off without a hitch. Partnership is essential.

In this case, we are talking about physicians, hospitalists, nurses, and administrators who directly interface with patients, their families, insurance companies and key outsiders such as needed vendors. They see what is happening and very often can bring ideas and perspectives that are extremely valuable.

Here is an example of bottom up perspectives. At a large hospital patient surveys revealed that the rooms were not thoroughly cleaned. Although this appeared to be a little thing on the surface, it created the impression that other parts of the hospital were not clean either. A change in process was recommended. Before leaving a patient’s room housekeepers asked patients if they had missed anything so it could be taken care of immediately. It turned out that patients had unique points of view from their hospital beds and could see things that the housekeeper could not. Generally patients were happy to offer guidance to the housekeeping staff. This change in procedure created only minimal additional activity for the housekeeping staff but significantly increased the patient survey ratings.

In many cases MIDDLE OUT represents the pivot roles and fills the gap between the vision (Top Down) and the operation (Bottom Up).

These Middle Out roles bridge the “here and now” with the “desired future state” and are often required to interpret (for operations) the system, structure, boundaries, and realities of the organization. They have to buffer the thinking and action on the part of top leadership while they themselves are leading and managing people who need validation and motivation every day. The middle is where compassionate thinking is critical.

SUMMARYmarvin #4

It takes all three entities to make large-scale change happen. Your innovation strategy as well as your people strategy needs a hands-on approach that involves and captivates individuals on all three levels. On a more detailed basis, all three entities need to look out of the organization for important collaborations that yield clues on how to be better.

Get more insights in PSX: People Strategy Exchange eMagazine. 


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